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Oxygen First Aid Instructor Manual

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DAN Oxygen Provider Course Standard Procedures. General This course, Oxygen First Aid for Scuba Diving Injuries, represents entry-level training designed to educate the general diving (and qualified non-diving) public to better recognise possible dive-related injuries and to provide emergency oxygen first aid while contact DAN Southern Africa and / or arranged for evacuation to the nearest available medical facility. Course Objective The course is designed to train and educate the general diving public in techniques of using oxygen as first aid for a suspected dive injury. In addition, this course will introduce novice divers to the fundamentals of recognising diving injury signs and symptoms, response and management. This program also provides and excellent opportunity for experienced divers and instructors to continue their education. The DAN Oxygen Provider course is not designed to train lay persons to provide oxygen to the general public. While the medical standards and equipment are the same regarding the emergency use of oxygen for both divers and non-divers, the DAN Oxygen Provider course does not prepare individuals to respond to the ill or injured member of the general public by using emergency oxygen. Recommended Minimum Hours of Training Knowledge development (lecture) hours = 1 Skills development (practice) hours = 3 This course should be taught as a four-hour module as outlined in this manual. The time needed to teach the course varies and depends on many factors including the number of students and their ability to process the educational components of the program. Instructors who want to include subjects or training beyond the course requirements may do so only before or following the course. Any additional training must no be required for completion of course requirements. Required Curriculum Subject Areas The instructor must ensure participants are familiar with each of the following: Knowledge Development

• General diving anatomy, physiology and physics • Reparatory system • Cardiovascular system • Recognition of signs and symptoms of specified diving emergencies • Near drowning • Decompression illness • Decompression sickness (DCS) • Arterial gas embolism (AGE) • Oxygen’s effects on the body • Benefits and concerns of using oxygen for a diving injury • Emergency oxygen delivery equipment • Purpose • Types • Features • Function • Care and Maintenance.

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The Instructor must ensure each course participant can successfully perform the following: Skills Development

• Scene safety assessment • Familiarity with the DAN Oxygen Unit • Perform adequate rescue breathing with associated knowledge of Basic Life Support • Operation of the DAN Oxygen Unit including use of the oxygen deliver devices

• Demand inhalator valve and mask • Constant-flow, non-rebreather mask • Oronasal resuscitation mask with supplemental oxygen.

Learning Objectives Course participants must be familiar with the signs and symptoms of major diving injuries including near drowning and decompression illnesses (arterial gas embolism and decompression sickness). Course participants must demonstrate proper deployment, assembly, disassembly, and use of all components of the DAN Oxygen Unit. This includes use of the demand inhalator valve + mask, constant flow (delivering oxygen up to 25 lpm), non-rebreather mask and oronasal resuscitation mask with supplemental oxygen inlet. Course participants must complete the DAN Oxygen First Aid for Scuba Diving Injuries examination with a minimum passing score of 80 percent. The instructor will review the examination with each participant to ensure 100 percent understanding of the material. Skills Performance Objectives To successfully complete the DAN Oxygen Provider course, participants must demonstrate skill and confidence during deployment, assembly and disassembly of all parts of the DAN Oxygen Unit (or other acceptable units). The course participant must demonstrate skill and confidence while providing emergency oxygen to simulate injured divers by:

1. Assessing the scene and oxygen provider safety 2. Deploying and operating the DAN Oxygen Unit 3. Selecting and preparing the appropriate oxygen mask 4. Operating the DAN Oxygen Unit and using these oxygen delivery devices:

• Demand inhalator valve and mask • Constant-flow, non-rebreather mask • Oronasal resuscitation mask with supplemental oxygen inlet

5. Identification of the main components of the DAN Oxygen Unit • Oxygen cylinder and valve • Multi-function regulator • “T” handle • Handwheel wrench • Constant-flow controller • Intermediate pressure hose • Pressure activated check valve (in threaded outlet) • Demand inhalator valve • Oronasal mask • Non-rebreather mask • Oronasal resuscitation mask with supplemental oxygen inlet

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DAN Support Materials The DAN Oxygen First Aid for Scuba Diving Injuries Student Kit is required to fulfil training requirements. Each DAN Oxygen Provider must possess the Student Handbook. Only DAN Instructors may acquire DAN Oxygen training and certification materials from DAN or its designated agent. At least one of these audiovisual support materials must be used during the knowledge development session of the DAN Oxygen Provider Course.

• DAN Oxygen first aid for Scuba diving Injuries slide series (67 slides) DAN Training recommends that these audiovisual support materials be used to supplement the DAN Oxygen Provider Course:

• Mystery of the Bends video (30 minutes) • This is DAN and Fitness to Dive videos (8 minutes)

DAN also recommends that each student receive a copy of: • DAN Pocket Guide to First Aid for Scuba Diving

DAN Oxygen Provider Retraining Standards General This is a retraining programme for DAN Oxygen Providers who have previously attended a DAN Oxygen First Aid for Scuba Diving Injuries Course. This retraining programme is not designed to train new DAN Oxygen Providers. Retraining Course Objective The objective of this course is to refresher and update previously trained DAN Oxygen Providers in necessary knowledge and skills. Qualifications Upon Completion Since the first aid skills associated with providing emergency oxygen first aid deteriorate at variable rates, DAN Training recommends retraining every two years. (24 months). Prerequisites for Entering the DAN Oxygen Provider Retraining Programme The course participant must show proof of having successfully completed a previous DAN Oxygen First Aid for Scuba Diving Injuries Course. Recommended Hours of Training Option 1 Participate in the 4-hour DAN Oxygen Provider Course Option 2 Knowledge development time = 1 hour: View DAN’s Oxygen First Aid for Scuba Diving Injuries video or slides series, review the DAN Oxygen Provider Workbook and pass a written evaluation. Skills development session time = 1 to 1.5 hours Required Curriculum Subject Areas The DAN Instructor must ensure that the following subject areas have been reviewed with the course participant.

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Knowledge Development • General diving anatomy, physiology and physics • Respiratory system • Cardiovascular system • Recognition of sings and symptoms of specified diving emergencies • Near drowning • Decompression illness

• Decompression sickness (DCS) • Arterial Gas embolism

• Oxygen effects on the body • Benefits and concerns of using oxygen for a diving injury • Emergency oxygen delivery equipment

• Purpose • Types • Features • Function • Care and Maintenance

The instructor must ensure that the course participant is able to successfully demonstrate the ability to perform the following skills: Skills Development • Scene safety assessment • Familiarity with the DAN Oxygen Unit • Perform adequate rescue breathing with associated knowledge of Basic Life Support. • Operation of the DAN Oxygen Unit including use of the these oxygen delivery devices:

• Demand inhalator valve and mask • Constant-flow, non-rebreather mask • Oronasal resuscitation mask with supplemental oxygen

DAN Support Materials for All Retraining Courses The DAN Oxygen First Aid for Scuba Diving Injures Student Handbook and re-certification envelope is required to fulfil retraining requirements, Each DAN Oxygen Provider participating in retraining must have the most current edition of the Student Handbook. If the DAN Oxygen Provider participating in retraining owns the most recent edition of the Student Handbook, the DAN Oxygen Instructor only needs to purchase a re-certification envelope. DAN Training will issue a new provider card and certificate as soon as the provider course refresher form is received. Only DAN Oxygen Instructors may acquire DAN Oxygen Training certification materials from DAN or its designated agent.

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Key Standards Overview DAN Oxygen Provider Course Recommended Prerequisites: DAN BLS (or equivalent*) Maximum Student-to-Instructor Ratio: 12:1 during skills development sessions Recommended course hours: Four Hours Required Student materials: DAN Oxygen First Aid for Scuba Diving Injuries Student Kit Required instructor materials: DAN Oxygen Instructor Manual Required audiovisual materials: DAN Oxygen First Aid for Scuba Diving Injuries video or DAN Oxygen First Aid for Scuba Diving Injuries slide series. Recommended retraining period: 24 Months *A CPR/Basic Life Support courses is equivalent to the DAN BLS course if this course follows the ERC guidelines and the certification is issued by a recognised first aid organisation. Certifications which meet this definition are accepted and don’t have to be confirmed by DAN Training prior to the course. However for a DAN Oxygen Provider please confirm prior to the course with DAN Training if the certificate held by the student meets equivalency requirements.

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Knowledge Development Session Outline and Slide Script

Knowledge Development Session Outline How to conduct the knowledge development session for the DAN Oxygen Provider course. Before you start: 1. Provide each student with a copy of the DAN Oxygen First Aid for Scuba Diving Injuries Student Kit. Each student must have a copy of the handbook. 2. Instruct students to read the handbook and complete the review questions before coming to class. 3. Review the DAN Oxygen Provider Course Checklist. Make sure that you have all materials and equipment required to teach the program. Knowledge Development Session Process: 1. Conduct introductions of the course staff and of the DAN Oxygen Provider Course. 2. Complete DAN Oxygen Provider Course administrative requirements (DAN Oxygen Provider Registration Form, Statement of Understanding, Practical Evaluation Record and other training association administrative requirements). 3. a) Show the DAN Oxygen First Aid for Scuba Diving Injuries video (50 minutes) (If available in the language of the students). You may stop the video to answer any questions. Or b) Show (61 slides) and review the DAN Oxygen First Aid for Scuba Diving Injuries slide script. When necessary, answer any student questions about the material. Or c) Show the DAN Oxygen First Aid for Scuba Diving Injuries video (50 minutes) and the DAN Oxygen First Aid for Scuba Diving Injuries slide series. Answer any student questions about the material. 4. Conduct the Skills Development Session emphasizing key portions of the Knowledge Development Session. 5. The Providing Care with an AED skill is an Optional Skill. DAN Instructors should demonstrate this skill within the Oxygen First Aid course as a means to cross-promote the AED course. 6. Administer the DAN Oxygen Provider Course Final Examination. Students must score at least 80 percent for successful completion of the course. To ensure 100 percent comprehension of the material, review any missed questions with the student. 7. Have students complete the DAN Oxygen Provider Course Evaluation and send them to DAN Training. 8. Sign DAN Oxygen First Aid for Scuba Diving Injuries successful completion cards and wall certificates for all successful course participants. 9. Congratulate and encourage all course participants to continue learning about dive safety and scuba diving. 10. Remind students that Oxygen Provider Skills deteriorate at variable rates and retraining is recommended every two years or 24 months.

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DAN Oxygen First Aid for Scuba Diving Injuries Slide Script

Slide 1: Oxygen First Aid for Scuba Diving Injuries Welcome to Divers Alert Network's Oxygen First Aid for ScubDiving Injuries course. My name is ___________ and I am certified DAN Oxygen First Aid Instructor.

Slide 2: Oxygen Provider Registration - Please complete the following administrative

paperwork. - DAN Oxygen Provider Registration Form - Statement of Understanding - DAN Membership Form [This is optional but

encouraged.] - Other Administrative Procedures [If you are teaching

the course as a distinctive specialty, have the students complete all necessary paperwork required by any other training association with which you are affiliated.]

- Introductions o Instructor and Staff o DAN Oxygen Provider Candidates o DAN Oxygen Provider Credentials

Since oxygen first aid skills deteriorate at variable rates, retraining is recommended every two years (24 months). However, as a Good Samaritan, you must only provide your best rescue efforts in good faith, based on your level of training and experience.

Slide 3: Oxygen Provider Course Overview During the DAN Oxygen Provider Course, the following topics will be reviewed: - What is DAN? - Anatomy and Physiology - Diving Injuries - Oxygen - Benefits of Oxygen

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Slide 4: Oxygen Provider Course Overview - Oxygen Equipment - Providing Oxygen First Aid - Recommendations for Oxygen Providers - Oxygen Provider Skills Development - Exam and Review

Slide 5: Oxygen Provider Course Overview This is an entry level course designed to train the general diving public (and interested persons who do not dive) to recognise the signs and symptoms of scuba diving injuries and provide oxygen to injured scuba divers at the highest possible concentration while activating the local Emergency Medical Services (EMS). Upon completion of this course, the DAN Oxygen Provider will be able to:

- Recognise the signs and symptoms of diving injuries.

- State the benefits of providing oxygen to an injured diver.

- List the potential hazards of handling oxygen and oxygen equipment.

- Demonstrate confidence and skill when providing oxygen first aid to simulated injured divers using the DAN Oxygen Unit.

- Demonstrate the use of each mask option for both breathing and non-breathing simulated injured divers.

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Slide 6: What is Divers Alert Network?

Slide 7: The Mission of DAN - Divers Alert Network (DAN), a non-profit organisation, exists to

provide expert information and advice consistent with current medical literature.

- DAN provides emergency medical advice and assistance for underwater scuba diving injuries, works to prevent injuries and promotes diving safety.

Slide 8: The Mission of DAN - DAN promotes and supports underwater diving research and

education, particularly as it relates to the improvement of dive safety, first aid and medical treatment.

- DAN provides accurate, up-to-date, and unbiased information on issues of common concern to the diving public and advocates for divers' concerns for diving safety.

Slide 9: DAN Services DAN provides these and other valuable services to the dive community. Contact DAN if you have any questions about DAN's services or about how to become a member of Divers Alert Network. [Review and highlight DAN's services. Details available in the What is DAN section at the front of the manual.]

- DAN Medicine o Diving Emergency Hotline (24 hours a day, 7

days a week) o Diving Medicine Information (9 a.m. - 5 p.m.

Eastern Time) o Chamber Assistance

- DAN Training - DAN Membership

o DAN Travel Assist (24 hours a day, 7 days a week)

o Alert Diver magazine o Dive accident & liability insurance

- DAN Research - DAN is Your Dive Safety Association!

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Slide 10: Anatomy and Physiology

Slide 11: Respiratory System - The respiratory system consists of the mouth, the nose, the

airways, the muscles between the ribs, the diaphragm and the lungs.

- Its function is to exchange gases between the body and the environment.

Slide 12: Respiratory System - The body requires a constant supply of oxygen to function. - The interruption of the supply of oxygen leads to hypoxia, or

an inadequate supply of oxygen to the body tissues. - The brain and other areas of the central nervous system are

the most affected by the lack of oxygen. - Hypoxia also impairs normal cell function and results in

tissue swelling (Oedema)

Note: The term hypoxia, used throughout this course, refers to an insufficient supply of oxygen to the tissues. If oxygen is not supplied to tissues in sufficient quantity, cells will begin to die. Since over 50 percent of the oxygenated blood coming from the heart goes directly to the brain, it is most susceptible to hypoxia. Hypoxia results in fluid buildup in the tissue spaces causing swelling or oedema. Providing oxygen first aid will help reduce oedema.

Slide 13: Respiratory System - Gas exchange is the uptake of oxygen from the air spaces in

the lungs and the removal of carbon dioxide from the blood. - Gas exchange occurs through the alveoli in the lungs.

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Slide 14: Circulatory System - The circulatory system consists of the heart, blood and blood

vessels. - Its function is to transport blood that carries oxygen, carbon

dioxide and other nutrients to cells of the body.

Slide 15: Respiratory and Circulatory Systems - Air contains approximately 21 percent oxygen and 79

percent nitrogen. - During respiration, the body uses only some of the

oxygen inhaled. - Exhaled air contains approximately 16 percent oxygen. - The combination of the respiratory and circulatory

systems provides the mechanism for gas exchange in the body.

Note: When air is inhaled into the lungs, it travels through a series of branching air passageways, called bronchioles, until it reaches the alveoli (air sacs). Once in the alveoli, the air is only separated from the blood stream by tissue that is one cell thick. At this point, gas exchange occurs between the lungs and the haemoglobin and oxygen is transported to the tissues via the bloodstream. As oxygen is used by the tissues carbon dioxide (CO2) is produced as a waste gas and diffused into the bloodstream. Carbon dioxide is transported back to the lungs and it is exhaled.

Slide 16: Diving Injuries

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Slide 17: The Nature of Diving Injuries - Recognition of a diving injury is based on these

indications: o Recent history of scuba diving o Presence of signs and symptoms

- There is no definitive test or unique set of signs or symptoms to confirm the presence of DCI for the rescuer.

- Diving injuries have a broad range of signs and symptoms.

- These signs and symptoms are similar to many other illnesses and injuries.

Slide 18: Diving Injuries - Immediate field First Aid in recreational diving accidents is

essential for best recovery without significant sequelae. (see note)

- The efficiency of Hyperbaric and Rehabilitation Treatment is favourably influenced by a timely and effective First Aid

- Expert Health Care Personnel is not always available on site: Every diver should be trained to recognise diving emergencies and to take immediate and correct action

- Diving causes significant behavioural and environmental dehydration. A diver can lose up to 2 litres of fluids during a dive

- If a diver is conscious and able to swallow autonomously: Give water (1 Litre) treatment.

Note: The word “Sequelae” refers to symptoms which are still present after medical

Slide 19: Near Drowning / Submersion Incident - Near drowning results from suffocation due to submersion in

water. - It impairs the ability of the lungs to perform gas exchange. - It may include aspiration of fluids into the lungs. - It results in hypoxia and possibly respiratory and cardiac

arrest. - Contributing factors include diver panic and over-weighting.

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Near drowning is the result of water being inhaled into the lung, impairing the body's ability to transfer oxygen to the bloodstream, resulting in hypoxia. A diver who has experienced a near drowning may appear alert, oriented and may deny a problem exists. However, a physician must evaluate this diver because a drowning victim's condition may deteriorate rapidly and without warning.

Slide 20: Near Drowning Warning Signs - Unconsciousness - Cyanosis (bluish colouration) - Shortness of breath - Coughing - Frothy Sputum

Slide 21: Decompression Illness - Decompression illness (DCI) is used to describe the signs

and symptoms of an injury caused by breathing compressed gas at depth.

- DCI encompasses both arterial gas embolism (AGE) and decompression sickness (DCS) injuries.

- First aid treatment for both AGE and DCS is the same. The role of an oxygen first aid provider is not to diagnose an injury but simply to recognise that a diving injury exists. Signs and symptoms may appear similar to other disorders. However, regardless of the diving injury or accident, the same first aid procedures should occur. The procedures include assuring and maintaining the injured diver's Airway, Breathing and Circulation (ABCs) and then providing appropriate oxygen first aid.

Slide 22: Arterial Gas Embolism - AGE is an over-expansion injury of the lungs. - Gas enters bloodstream (pulmonary veins). - Gas travels to heart and arterial system. - Gas may block major arteries. - Gas cuts off supply of oxygenated blood. - AGE commonly affects brain.

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In the case of arterial gas embolism (AGE), also known as air embolism, air is trapped in the alveoli and expands during the diver's ascent. As the ascent and air expansion continue, air may be forced through the thin alveolar lining directly into the bloodstream, with little or no physical damage to lung tissue. Alternately, air expansion may cause the alveoli to rupture introducing air either into the bloodstream or into the surrounding tissues. Air introduced into the bloodstream returns to the heart and may go directly to the brain causing symptoms that are rapid and dramatic.

Slide 23: Arterial Gas Embolism - AGE often has rapid and dramatic symptom onset. - Contributing factors may include rapid ascent, breath

holding, lung damage, lung congestion, asthma or other air-trapping mechanism.

- AGE may accompany other pulmonary barotrauma. - AGE is the most serious result of a lung-expansion injury. AGE occurs as a result of a lung overpressure injury while ascending from depths as shallow as 4 feet / 1.2 meters. Air is introduced into the bloodstream, returns to the heart and may go directly to the brain causing symptoms that may be rapid and dramatic. Contributing factors for an AGE may be a rapid ascent, breath-holding on ascent, lung congestion, some forms of asthma, or lung damage due to a previous injury. Also, AGE may occur for no apparent reason.

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Slide 24: Decompression Sickness - The body's tissues absorb nitrogen during the dive. - DCS is the result of bubble formation and growth during and

after ascent. - Its effects can include distortion or tearing of tissue,

reduction or stoppage of blood flow, and activation of blood clotting mechanisms.

Decompression sickness (DCS) is the result of excess nitrogen absorbed into the tissues from the dive, forming into bubbles on ascent. The formation of these nitrogen bubbles may cause direct tissue damage or the bubbles may block the flow of oxygenated blood to tissues including the spinal cord. Symptoms of DCS in divers often are described as vague and may be ignored until the symptoms get worse or persist.

Slide 25: Decompression Sickness - DCS usually has delayed symptom onset. - Contributing factors for bubble formation include excess

nitrogen, rapid ascent and decreasing pressure such as flying after diving.

- Bubbles as a result of DCS cause various signs and symptoms based on their location.

- Any area of the body may be involved. - Since first aid for DCI is the same, avoid trying to identify the

type of injury (AGE or DCS) and provide oxygen.

Slide 26: Common Warning Signs According to the DAN decompression illness and fatalities statistics, the most common warning signs of DCI are: - Numbness - Pain - Headache - Weakness - Dizziness - Unusual fatigue - Nausea - Difficulty walking

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Slide 27: Other Warning Signs A wide variety of additional warning signs of diving injuries can occur. The following signs, gleaned from the DAN DCI and fatalities data, are listed in descending order according to frequency of occurrence: - Altered skin sensation - Rash and itching - Difficulty breathing - Visual disturbance - Restlessness - Paralysis - Muscle twitching - Unconsciousness - Vertigo - Personality change - Speech disturbance - Altered level of responsiveness - Bladder / bowel problems - Hearing changes - Coughing up blood or sputum - Mental confusion - Ill feeling

Slide 28: Important Notes About DCI Warning Signs - DCI usually involves multiple warning signs. - Onset time for DCI varies from during the dive up to 24

hours or more following a dive. - Most serious signs and symptoms occur within the first two

hours following a dive. - Any sign or symptom following a dive must be considered as

potentially due to DCI. - Every symptom occurring after breathing of compressed

gas at any depth and any time requires Oxygen First Aid and specialized medical advice or the assistance of DAN

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Most diving injuries do not result in severe signs and symptoms. Few dive injuries reported to DAN are catastrophic in nature. Due to the nature of the injury, the signs and symptoms of AGE are generally rapid and dramatic. The average symptom onset time is one minute for both the first and second symptom. In some cases the injured diver may experience symptoms while still underwater, which could lead to a near-drowning incident. Since the offending bubbles in DCS may take time to evolve in the blood or other tissues, the average symptom onset time is 20 minutes to two hours after surfacing. Post-dive activities may enhance the formation of bubbles and include:

- Post-dive exercise - Taking a hot shower - Alcohol consumption - Exposure to altitude - If you suspect that you are injured after diving, you may

be. Call DAN if you have any questions or concerns.

Slide 29: Warning Sign Recognition - Recognition of signs and symptoms is the first step in

managing a diving injury. - The injured diver is less likely to have residual symptoms

when definitive treatment at a recompression facility is provided soon after the onset of signs and symptoms.

- If you're not sure what to do or if you have questions, call DAN for referral to the nearest appropriate medical facility.

Slide 30: Oxygen

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Slide 31: What is Oxygen? - Oxygen is the essential component of air that sustains life.- Oxygen is a colourless, odourless and tasteless gas. - Oxygen is also used for medical purposes to prevent or

treat hypoxia in an emergency and for long-term medical care.

Note: The recommendations made in this course comply with the guidelines established by the Emergency Cardiac Care Committee published in Journal of the American Medical Association (ECC / JAMA), the European Resuscitation Council guidelines 2005 for Adult Basic Life Support and the American Heart Association’s “Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.” which states that "oxygen should not be withheld out of fear of suppressing respiration if hypoxia is suspected." The mechanism behind all dive injuries is hypoxia. "Out of fear of suppressing respiration" refers to providing oxygen to persons with severe chronic obstructive pulmonary disease (COPD). Persons with this disease may stop breathing if they receive high concentrations of oxygen. This is not a concern when providing oxygen to injured divers since those with severe COPD or similar conditions should have been medically screened and disqualified from scuba diving.

Note: If an injured diver is not breathing, the JAMA guidelines recommend that mouth-to-mask ventilations with supplemental oxygen should be used at the earliest possible moment. This increases the concentration of oxygen during ventilations from approximately 16 percent to over 50 percent.

Slide 32: Oxygen Cylinder Filling - Oxygen grades

o Use only medical or higher-grade oxygen suitable for breathing.

- Oxygen cylinder filling requirements o Prescription o Documentation of training o Other

- Oxygen laws and regulations

Note: Describe any local regulations, laws, or codes of practice regarding oxygen cylinder filling requirements and grades of oxygen used for diving emergencies. It is possible that, in order to fill an oxygen cylinder, you need to provide the oxygen cylinder refill station either a prescription or provide documentation of training in the use of emergency oxygen.

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Slide 33: Hazards of Breathing Oxygen - Oxygen poisoning or toxicity can occur by breathing high

concentrations of oxygen for an extended period of time. - There are two forms of oxygen toxicity that may concern

divers: o Central nervous system (CNS) oxygen toxicity

occurs when breathing oxygen at higher than atmospheric pressure.

o Pulmonary oxygen toxicity occurs when exposed to 100 percent oxygen over a period of several hours without air breaks.

Neither form of oxygen toxicity is a concern for the DAN Oxygen Provider rendering first aid to an injured scuba diver. CNS and pulmonary oxygen toxicity are potential risks for both technical divers and divers who use enriched air Nitrox.

Slide 34: Oxygen Safety To reduce the risk associated with using oxygen, follow these safety measures while using oxygen:

- Extinguish all flames and smoking material. - Do not use oxygen in the presence of oils, grease or

flammable substances. - Always use oxygen in well-ventilated areas. - Use only equipment designed for use with oxygen. - Maintain and service oxygen equipment as required. [It is

recommended that DAN oxygen equipment be serviced according to manufacturer’s recommendations.]

- Always secure oxygen cylinders during transport.

Slide 35: Benefits of Oxygen - Diving injuries or accidents may result in:

o Blocked blood supply to various body tissues. o Damaged tissues obstructing effective gas

exchange. - Breathing high concentrations of oxygen increases the

pressure gradient needed to eliminate nitrogen. - To give the greatest benefit for the injured diver, provide

the highest concentration of oxygen possible - 100 percent oxygen is recommended.

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Slide 36: Benefits of Oxygen Oxygen first aid may provide these important benefits: - Reduce bubble size - it increases the pressure gradient from

the bubble to the surrounding tissues to allow for a more efficient elimination of nitrogen.

- Oxygenate hypoxic tissues - oxygen first aid results in increasing oxygen levels in hypoxic tissue.

- Reduce tissue oedema - tissue swelling may be reduced due to reversing the hypoxic process and because oxygen is a mild vasoconstrictor.

- In some cases, increased oxygen concentrations may ease breathing.

- Relieve symptoms. - Reduce the risk of residual symptoms after hyperbaric

treatment.

Note: The Photo on this slide shows bubbles in a bloodstream.

Slide 37: Interaction between O2 transport, hydration, circulating gas bubbles and cellular tissue sufferance In normal blood-flow conditions oxygen diffuses from the capillaries with a high pressure gradient and the intra-capillary tissues are normally oxygenated

Slide 38: Interaction between O2 transport, hydration, circulating gas bubbles and cellular tissue sufferance Intravascular gas bubbles are a mechanical obstacle to circulation and reduce O2 transport capacity, blood oxygen partial pressure decreases, oxygen diffusion gradient is lowered. Tissues and cells suffer.

Slide 39: Interaction between O2 transport, hydration, circulating gas bubbles and cellular tissue sufferance Capillary cells suffer also and let water leak from capillaries to tissues, blood flow is thus further impaired, oxygen transport is decreased, and tissue lesions may occur

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Slide 40: Interaction between O2 transport, hydration, circulating gas bubbles and cellular tissue sufferance Capillary water leakage causes tissue swelling (oedema), this increases Intra-capillary distance and further impairs tissue oxygenation

Slide 41: Oxygen Equipment

Slide 42: Oxygen Equipment Follow these general rules about using oxygen equipment to assist an injured diver:

- Demand system is preferable over a constant-flow system because...

- 100 percent oxygen may be provided. - Oxygen is not wasted. - Cylinder capacity should allow for oxygen to be provided

from the dive site to the nearest medical facility. - Receive training for the oxygen delivery device you plan

to use. - Check oxygen equipment and cylinder pressure before

every dive outing.

Slide 43: Oxygen Equipment An oxygen delivery system consists of these four / five components: - Cylinder - Adapter (optional) - Regulator - Oxygen tubing or hoses - Oxygen mask

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Note: The oxygen first aid provider must provide oxygen to injured divers at concentrations as close to 100 percent as possible. A properly used demand valve is capable of delivering up to 100 percent oxygen to injured divers and at the same time conserve oxygen. It is unlikely that a constant flow device will deliver close to 100 percent oxygen even with the best mask option and provider technique. [Remind students that all concentrations of oxygen delivered to an injured diver ultimately depend on the fit of mask and oxygen provider technique.]

- Slide 44: Oxygen Cylinders - Types - In Europe you will find different types of oxygen cylinders

(2, 2.5, 3, 5 litres). - A 2 litre tank can hold (if filled at 200 Bars) 400 litres of

oxygen and lasts approximately 35’ when used with a demand valve. A 5 litre tank can hold 1000 litres of oxygen and will last about 80-90’ when a demand valve is used. [Describe the types of oxygen cylinders that are available locally.]

- Material - The two common materials used to manufacture oxygen

cylinders are aluminium and steel. Aluminium oxygen cylinders are lightweight and compact. In Europe however, you will find almost only the steel ones.[Describe any other materials used for oxygen cylinders that are available locally.]

- Valves - There are many styles of oxygen cylinder valves used

throughout the world. Every European country has its own standard tank valve and most of the time the pin-index tank valve is available as well. The Pin index tank valve is the one used in the USA. In order to make your local tank valve fit on the DAN Europe Multi Function Regulator (which has a DIN 477 fitting), DAN works with adapters. These Adapters are make it possible to connect the regulator to every kind of tank valve. This can also be an advantage, when using your unit in another country with another type of tank valve. You will only need another adapter to make it fit. [Describe the types of oxygen cylinder valves that are used locally.]

- Colour-Coding - Oxygen cylinders are colour-coded to reduce the risk of

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using a cylinder for an unintended purpose. In Europe, oxygen cylinders are coded with the colour white. [Describe local oxygen cylinder colour-coding schemes.]

- Labelling - Oxygen cylinders are labelled so that the purchaser of the

product (the cylinder and its contents) is made aware of the name and address of the manufacturer and / or distributor / re-filler, the product name, contents in unit of measure (litres or cubic feet), expiration date (if required), lot number, method of production and any precautionary statements. [Describe local labelling requirements and show label of oxygen cylinder.]

- Maintenance - Oxygen cylinders should be visually examined for any

signs of corrosion, damage or rust. Cylinder should be examined to ensure it is within current hydrostatic testing dates.

o Hydrostatic testing - In Europe, oxygen cylinders must be hydrostatically

tested every five years. [Describe local hydrostatic testing periods.]

o Storage - It is important to ensure that oxygen cylinders are

properly stored to reduce the risk of accidentally dropping it. Secure oxygen cylinders when they are not in use. When using oxygen equipment to assist an injured diver, put the oxygen cylinder down and secure it.

- Other recommendations: - Have enough oxygen to get the injured diver to definitive

medical treatment. Additional oxygen cylinders may be necessary.

- In Europe and many other countries, the valves on portable oxygen cylinders have system (standardised tank valve) to prevent the use of incompatible regulators with oxygen cylinders.

- Use only equipment specifically designed for use with oxygen.

- Adapting scuba equipment for oxygen service may constitute a combustion hazard. [Show various oxygen cylinders and the system found on the oxygen cylinder

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valve.]

- Slide 45: Oxygen Regulators - Purpose - The purpose of an oxygen regulator is to take the oxygen

inside the cylinder and reduce the pressure to one that can be delivered to an ill or injured person via a delivery device.

- Styles o Demand: provides oxygen when a demand valve is

activated and is similar to a scuba regulator's first stage. Demand regulators have Diameter Indexing Safety System (DISS) outlets for demand valves or other life support equipment.

o Constant flow: provides a constant flow of oxygen that is either preset or adjustable.

o Multifunction: combines features of both demand and constant-flow oxygen regulator systems where they can provide oxygen by demand valve or by adjustable constant flow. These two features can be used independently, so that the oxygen provider could provide oxygen to two injured divers simultaneously.

- Features o Flow rates, which are important features of oxygen

regulators, and DAN recommends that oxygen regulators be able to provide at least 15 litres per minute (lpm) and up to 25 lpm.

All DAN Multifunction Regulators have a

constant-flow feature: For breathing and non-breathing divers. To provide oxygen to two injured divers

simultaneously when used in conjunction with demand inhalator valve.

To provide oxygen at a flow rate of up to 25 lpm.

For use with a variety of oxygen masks.

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- Adapters o The DAN Europe Multi Function Regulator can be

used with a wide variety of adapters. These kind of adapters make it possible to connect the DAN Europe Regulator to almost every kind of tank valve.

Multifunction Regulator Notes: The constant flow controller is on one end of the regulator body. On the front of the regulator, one can see the flow rate through the view window. Below the window is the barbed, constant-flow outlet. Once the clear plastic oxygen tubing is attached to the barbed outlet, oxygen can flow directly to the selected oxygen mask. [Show a multifunction regulator and other oxygen regulators if available.]

Demand Valve Notes: Since oxygen is only used when the injured diver inhales, the demand valve will extend the oxygen delivery time of the cylinder. The demand inhalator valve with an oronasal mask functions just like a scuba regulator; however, it cannot be used underwater. Note that there is no button on this style of demand valve for assisted resuscitation. Once the rescuer has started providing oxygen, injured divers can hold the mask if they are responsive. The rescuer should continue to monitor the injured diver and look and listen for the signs of breathing. Avoid leaving an injured diver unattended. MTV-100 Note: For assisted resuscitation DAN uses the MTV-100 valve (with button). In order to train Oxygen Providers in the use of this kind of demand valve, DAN has developed the Advanced Oxygen first Aid Program.

- Slide 46: Demand Inhalator Valve - Provides 100 percent oxygen and 100 percent

of the injured diver respiratory needs. - Can be used with breathing divers only. - Efficiently uses oxygen. - Must be used with an oronasal delivery mask

such as o Oronasal mask o Oronasal resuscitation mask

- [Show the demand inhalator valve and appropriate oronasal masks.]

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Slide 47: Non-rebreather Mask - Can be used with breathing divers only. - Has a recommended initial flow rate of 15 lpm. - Has a reservoir bag that must be primed and

kept inflated while it is used to provide oxygen to an injured diver.

- Its use is recommended when there is: o Second injured diver. o Demand valve is not tolerated.

Non-rebreather mask notes: Non-rebreather masks provide high concentrations of oxygen but depend on the seal of the mask on the injured diver's face and the flow rate. Ensure that the reservoir bag remains inflated. If the reservoir bag deflates to less than a third full, increase the flow rate to 25 lpm or switch to the demand inhalator valve. Note: DAN recommends that all oxygen delivery masks should be clear to allow the rescuer to monitor divers airway and breathing.

Slide 48: Oronasal Resuscitation Mask - May be used with both breathing and no breathing

diver - Has a recommended flow rate of 15 lpm. - Provides increased oxygen concentration up to 50

percent versus only 16 percent with only one's expired breath.

- Are effective barrier devices when appropriate one-way valves and filters are used.

Oronasal resuscitation mask notes: The oronasal resuscitation mask may be used with the demand inhalator valve for breathing injured divers. It may also be attached to tubing and the constant-flow outlet barb on the regulator for non-breathing injured divers. There are many similar styles of oronasal resuscitation mask and are suitable for use with injured divers. Aid in rescue breathing with supplemental oxygen when a person is not breathing.

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Slide 49: MTV Features of the flow-restricted oxygen powered ventilator (FROPV) include the following: - It can provide 100 percent oxygen for both

breathing and non-breathing injured divers. - It uses a demand valve for breathing injured

divers. - Its manually triggered ventilator allows for use

with non-breathing injured divers. - It requires additional training. [introduce the

Advanced Oxygen First Aid Program to your students.]

Note: Flow restricted oxygen powered ventilation (FROPV) device can provide oxygen on demand to a breathing injured diver. It will also allow a trained rescuer to manually ventilate a non-breathing injured diver. Since this equipment requires extensive training and frequent practice to maintain the appropriate level of proficiency, DAN does not recommend the use of this device by untrained personnel. DAN Europe has developed an Advanced Oxygen First Aid Program to train Oxygen Provider in the use of this valve (and Bag Valve Mask).

Slide 50: DAN Oxygen Units - Provide 100 percent oxygen. - Can be used for both breathing and non-breathing

injured divers. - Can provide oxygen to multiple injured divers at

the same time. - Are housed in a waterproof case. - Include various cylinder sizes and numbers based

on time to reach definitive medical treatment. DAN offers a variety of oxygen delivery systems for diving injuries based on the above criteria. Contact DAN if you have any questions about oxygen equipment.

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Slide 51: Skills Development Session Overview

Slide 52: Scene Safety Assessment Remember S-A-F-E

- S - Stop (Stop, think, act while locating barrier devices and oxygen unit.)

- A - Assess scene. (Is diving equipment secure? Have divers been recalled? Is ventilation adequate? Any other hazards present?)

- F - Find and secure first aid kit, oxygen unit and automated external defibrillator, if available.

E - Exposure protection. (Locate and use barriers such as gloves and mouth-to-mask barrier devices.)

Note: Remember to save yourself first and to use barrier devices. Avoid rushing to help without thinking first. Avoid contact with blood and other bodily fluids. Proper ventilation for oxygen use requires extinguishing smoking materials. Avoid oils, grease and other contamination. Avoid enclosed areas.

Slide 53: Initial Assessment with Basic Life Support: Adult BLS sequence

- Remember SAFE - Unresponsive?

o Shout for help o Open airway

- Not breathing normally? o 30 chest compressions o 2 rescue breaths

For victims of drowning: Give 5 initial rescue breaths before starting chest compressions and perform 1 minute of CPR before getting help

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Notes: - The complete and detailed adult BLS sequence can be found on the “Skills

Development Session Overview” pages of your DAN Oxygen Instructor Manual.

- In the first minutes after cardiac arrest, an injured person may be barely breathing, or taking infrequent, noisy gasps. Do not confuse this with normal breathing. If you have any doubt whether breathing is normal, act as if not normal.

- If there is more than one rescuer present, another should take over CPR every 1-2 minutes to prevent fatigue. Ensure the minimum delay during the changeover of rescuers

- For victims of drowning: Give 5 initial rescue breaths before starting chest compressions and perform 1 minute of CPR before getting help

This course is not designed to teach one to perform cardiopulmonary resuscitation (CPR). Students can practice some of these techniques as part of this course, but any first aid procedure must begin with a primary assessment. Evaluating the airway, breathing and circulation (the ABCs) as taught in CPR courses. Oxygen first aid may be ineffective if this critical procedure is not performed properly. If the injured diver is responsive, breathing and circulation are assured. Remember to keep the airway open at all times. Avoid lifting the neck to open the airway.

Slide 54: Providing Care with an AED (Optional) - Unresponsive

o Shout for help - Not breathing normally?

o Send or go for AED and call EMS o Call EMS o CPR 30:2 until AED is attached

- Attach the defibrillator pads - Allow the AED to analyze heart rhythm

o Don't touch the patient - If shock required:

o Follow the AED unit's prompts o Visually and physically clear the patient o Say “Clear” o Administer shock.

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o Resume CPR 30:2 for 2 minutes o Continue as directed by the voice/visual

prompts If no shock required:

o Continue CPR 30:2 until the injured person starts to wake up, open eyes and to breathe normally

o Continue as directed by the voice/visual prompts

Note: If the injured person is in cardiac arrest, CPR can assist in sustaining the person until medical help arrives, but it cannot restart the heart. Only a defibrillator can do that. The AED pads should be placed on the injured person's chest according to the diagrams on the pads and then the first aid provider should follow the unit's prompts. Note: The Providing Care with an AED skill is an Optional Skill. DAN Instructors should demonstrate this skill within the Oxygen First Aid course as a means to cross-promote the AED course.

Slide 55: Demand Inhalator Valve For breathing injured divers, the demand inhalator valve is preferred in providing oxygen. To use this device, follow the previous steps plus the following ones.

- Deploy the oxygen unit and check its function and cylinder pressure.

- Say the oxygen use statement, "This is oxygen and it may make you feel better. May I help you?"

- Provide oxygen via demand valve and oronasal mask. Check for any leaks.

- Reassure and comfort the injured diver. - Monitor the injured diver by assuring breathing.- Activate the emergency plan by calling EMS

and DAN for assistance.

Note: DAN recommends that all oxygen delivery masks should be clear to allow the rescuer to monitor diver’s airway and breathing.

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Slide 56: Non-rebreather Mask When the demand valve is not tolerated or when there is a second injured diver, use a non-rebreather mask to provide oxygen. To use this device, follow the previous steps plus the following ones.

- Attach mask to regulator by connecting the oxygen tubing to the constant flow barb.

- Set regulator flow rate to 15 lpm. - Prime reservoir bag by placing a thumb or

finger inside the nosepiece and seal the non-return valve until the reservoir fully inflates.

- Place non-rebreather mask on the diver's face. - Check for leaks around the mask edges.

Monitor injured diver by assuring breathing and making sure the reservoir bag does not fully deflate.

Non-rebreather mask notes: This mask has a 750 ml reservoir bag into which the oxygen flows. The injured diver inhales oxygen from the reservoir bag and exhales through the one-way valves on the sides of the mask as the reservoir bag refills with oxygen. The injured diver does not inhale (or rebreather) any of his or her exhaled air (thus the name non-rebreather mask).

The non-rebreather mask:

- Can be used for breathing divers only. - Can be used for a second breathing injured diver if

another injured diver is already using the demand inhalator valve.

- Reservoir bag must be primed prior to providing oxygen.

- Requires a rescuer to always monitor the injured diver and keep the reservoir bag inflated while providing oxygen.

- Has a recommended minimum flow rate of 15 lpm. The non-rebreather mask is connected to the barbed outlet with the clear oxygen tubing. Stretch the tubing to eliminate any kinks. After opening the cylinder valve one full turn, prime the reservoir bag and adjust the constant flow setting to 15 lpm.

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Note: Oxygen concentrations of the non-rebreather mask will vary depending on technique, mask seal and flow rate. Note: DAN recommends that all oxygen delivery masks should be clear to allow the rescuer to monitor divers airway and breathing.

Slide 57: Oronasal Resuscitation Mask When an injured diver is not breathing, use an oronasal resuscitation mask with supplemental oxygen to provide the highest concentration of oxygen possible. To use this device, follow the previous steps plus the following ones:

- Prepare oronasal resuscitation mask. - Attach oxygen tubing from the non-rebreather

mask to the regulator and oronasal resuscitation mask.

- Set oxygen flow rate to 15 lpm. - Maintain open airway. - Perform rescue breathing.

Oronasal Resuscitation Mask Notes: Rescue breathing with this style of resuscitation mask allows for mouth-to-mask resuscitation using supplemental oxygen. This mask is used for non-breathing divers and delivers increased oxygen concentrations depending upon flow rate and technique. It also reduces the risk of disease transmission. The thumbs should be placed parallel on both sides of the mask to create an airtight seal with the remaining fingers lifting the jaw while tilting the head back. Use previously learned procedure, blowing into the mask, to perform rescue breathing. Observe the injured diver's mouth through the clear mask to ensure an open airway. Also, do not delay rescue breathing in order to obtain oxygen. Avoid forceful or rapid ventilations.

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Slide 58: Proper Positioning The position in which you place the injured diver is important. Follow these guidelines when assisting an injured diver with emergency oxygen first aid: Positioning:

- If the diver is breathing and responsive, o Place the injured diver in either

supine or recovery position. - If the diver is breathing and unresponsive,

o Place the injured diver in the recovery position.

- If the diver is not breathing, o Place the injured diver in the supine

position.

Positioning Notes: The recommended position is supine (flat on back) or if there is a risk of vomiting, place the injured diver on his side (usually left) with head supported at a comfortable angle. The Trendelenburg position (head-down position) is no longer the recommended position for treating injured divers. The condition of the injured diver may actually worsen when placed in the Trendelenburg position. Fluids should be given to injured divers only if they are alert, have no difficulty breathing and can tolerate small sips of liquid. Since it is important to re-hydrate, water is the recommended fluid. However, other non-carbonated, non-alcoholic or non-caffeinated beverages are also acceptable for an injured diver.

Slide 59: Disassemble, Clean and Assemble the Unit Follow these steps to disassemble, clean and assemble DAN Oxygen Units.

- Depressurise system. - Refill (or change) oxygen cylinder if oxygen

supply is depleted. - Clean masks and other parts as directed.

[Review cleaning procedures for oxygen equipment.]

- Air-dry the disassembled parts. - Check oxygen washer. - Reassemble the oxygen unit and store it ready

for use.

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Slide 60: Emergency Assistance Plan - Diver Information

Name Age or Date of birth Address Emergency contact phone Current complaint(s) Past medical history including

current medication Dive profile(s) Drug allergies

- General Information Emergency contact information

(EMS, DAN) Initial contact phone number (Call

back #) Directions to nearest medical

facility DAN phone numbers Other

Slide 61: Recommendations for Oxygen Providers

Slide 62: Oxygen Provider Flowchart - Oxygen Provider Flowchart - The flow chart outlines the procedure an

oxygen first aid provider should follow when selecting the mask option when providing oxygen to an injured diver.

o The rescuer's primary consideration is to establish and maintain the injured diver's Airway, Breathing and Circulation (ABCs).

o The recommended first aid position for an

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injured diver to be flat on the back. If the rescuer feels that the injured diver is likely to vomit, he or she may elect to place the diver on his side, usually the left, with the head supported.

o Provide the highest possible concentration of oxygen. The primary option for breathing divers is by demand inhalator valve. The second best option for breathing divers is by non-rebreather mask. For non-breathing divers, rescue breathing using the oronasal resuscitation mask with supplemental oxygen is recommended.

o Use your emergency assistance plan to contact the local Emergency Medical Services (EMS) so they can transport injured to the nearest available medical facility.

o Call DAN if further assistance is required.

Slide 63: Recommendations for Oxygen Equipment Use Follow these general recommendations for Oxygen Equipment Use.

- Check oxygen unit and cylinder pressure before every dive outing.

- Oxygen unit should remain assembled and turned off.

- Always carry enough cylinders to provide continuous oxygen while awaiting the arrival of EMS. Extra washers and masks should be included whenever possible.

- Clean masks after each use. - Professionally service oxygen equipment every

two years or according to manufacturer's recommendations.

- Use oxygen in well ventilated areas only - Extinguish all burning materials - Avoid contact with any grease

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Slide 64: Recommendations for Oxygen Providers Follow these general recommendations for Oxygen Providers:

- Remember scene safety assessment - SAFE. Protect yourself first.

- Ensure the Airway, Breathing and Circulation (ABCs).

- Provide the highest concentration of oxygen possible and as long as the supply lasts. For breathing injured divers, use the demand inhalator valve.

- Have enough oxygen supply on hand to supply high concentrations of oxygen until emergency medical services arrive.

- Practice oxygen first aid skills frequently. - Place the injured diver in the appropriate first aid

position, flat on the back, or in the recovery position if there is a risk of vomiting.

- Provide the highest concentration of oxygen as long as the supply lasts.

Oxygen First Aid trained divers means faster Field First Aid, more effective specialized DAN Support, better clinical results!

Note: It is always more beneficial to the injured diver to provide the highest concentration of oxygen while the supply lasts rather than attempt to extend the supply by giving the diver air breaks or reducing the flow rate. Remember that the goal is to increase the pressure gradient to allow for the most efficient elimination of nitrogen.

- Continue providing emergency oxygen until the oxygen supply is depleted. There are only two circumstances when you would consider temporarily discontinuing the use of oxygen:

1. If the injured diver vomits. 2. If the injured diver experiences a seizure or

convulsion. In these situations, remove the mask temporarily until the injured diver either stops vomiting or the seizure is over,

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re-evaluate the ABCs, and resume the use of oxygen at the earliest possible moment.

- Never leave an injured diver alone unless the diver is not breathing and EMS must be contacted.

- Remember that the initial minimum flow rate, when using the constant flow feature of the regulator, is always 15 lpm.

- Always use oxygen in a well-ventilated area. When oxygen is used in a confined, poorly ventilated space (for example, inside a boat’s cabin), oxygen concentrations may constitute a combustion hazard.

- Never allow smoking near oxygen, and do not use oxygen near an open flame or other ignition source.

Slide 65: Oxygen and the Law - Good Samaritan Laws [Review Good

Samaritan Laws.] - Providing oxygen to an injured diver improves

the diver's chance of complete recovery. - Providing oxygen can cause no further harm to

an injured scuba diver. - Local oxygen laws and regulations [Describe

local oxygen laws and regulations.] Equipment requirements Oxygen cylinder filling requirements Other

There are often questions regarding liability coming to the assistance of another person. Good Samaritan Laws (in the United States and some other countries) generally protect those who use first aid skills to assist an injured person. As long as the rescuers perform skills considered a standard of practice and as long as they are within the scope of their training and experience, they will incur little risk of liability for coming to someone's aid. Consider these factors about emergency oxygen use: - Oxygen first aid is the recognised standard of

care for the field management of diving injuries. - No medical contraindications exist for providing

oxygen to injured scuba divers.

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- In Europe there is no standard for oxygen first aid.- Current laws are ill-defined. - Heed local or regional regulations.

Slide 66: Oxygen Provider Skills Development Session During the skills development session, these exercises and scenarios will be conducted:

- Scene safety assessment - Initial assessment with Basic Life Support - Providing care with an AED (Optional) - Injured diver scenarios using:

Demand inhalator valve Non-rebreather mask Oronasal resuscitation mask with

supplemental oxygen - Emergency Assistance Plan - Equipment assembly and disassembly

Slide 67: Oxygen Provider Course Summary During the knowledge development session, the following topics were reviewed:

- What is DAN? - Anatomy and Physiology - Diving Injuries - Oxygen - Benefits of Oxygen - Oxygen Equipment - Providing Oxygen First Aid - Recommendations for Oxygen Providers - Oxygen Provider Skills Development

By attending the DAN Oxygen Provider course, you have demonstrated your commitment to diving safety and have become an important part of the dive accident solution. In the unlikely event that you should encounter a scuba diving emergency, remember to:

- Make a primary assessment. (Establish and maintain an open Airway, Breathing and

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Circulation or the ABCs.) - Provide the highest concentration of oxygen for

as long as the supply lasts. - Activate the local or regional EMS or evacuate

to the nearest medical facility. - Call DAN for help or to ask questions.

In the rare event that a diving injury occurs or emergency does arise, you will be able to act with skill and confidence when assisting an injured scuba diver using emergency oxygen first aid. There are often questions regarding liability coming to the assistance of another person. Good Samaritan Laws (in the United States and some other countries) generally protect those who use first aid skills to assist an injured person. As long as the rescuers perform skills considered a standard of practice and as long as they are within the scope of their training and experience, they will incur little risk of liability for coming to someone's aid. Consider these factors about emergency oxygen use: - Oxygen first aid is the recognised standard of

care for the field management of diving injuries. - No medical contraindications exist for providing

oxygen to injured scuba divers. - In Europe there is no standard for oxygen first aid.- Current laws are ill-defined. - Heed local or regional regulations.

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Skills Development Session Overview How to conduct the skills development session for the DAN Oxygen Provider course. Pre-course Preparation: 1. Review the DAN Oxygen Provider Course Checklist. Make sure that you have all materials and equipment required to teach the program. 2. Review Ratios:

• Maximum student-to-Instructor ratio is 12:1. Additional students may be added with the use of certified assistant to a maximum of 21 students.

• Recommended student-to-CPR manikin ratio is 6:1. • Recommended student-to-oxygen training unit ratio is 3:1. • Recommended student-to-AED unit is 3:1.

3. Each DAN Oxygen Training Unit must include: • Multifunction regulator • Demand inhalator valve with hose • Oronasal resuscitation mask with supplemental oxygen inlet • Oxygen cylinder (e.g., 2, 3, 5 litres) filled with medical- or higher-grade oxygen

4. Each DAN Oxygen Training Unit should include: • Oronasal mask

5. Provide a non-rebreather mask to each DAN Oxygen Provider student. A non-rebreather mask, which is a disposable, one-time use medical device, cannot be cleaned and must not be shared between students. However, students may choose to keep their own non-rebreather mask for future use. 6. Check each oxygen training unit for proper functioning, DAN Oxygen Training Units, should be fully assembled with the oxygen supply turned off and depressurised, just as they would be found in the case of an emergency. 7. Prepare two washbasins to clean masks between student use. The first basin should be a bleach solution with a concentration of approximately 1:100 (1/4 cup of bleach in one gallon of water or 60 millilitres of bleach in 4 litres of water) and a second basin with water. Have paper towels or other drying devices available. 8. Optional AED Exercise equipment

• Must be a training version of an automatic or semi-automatic external defibrillator approved for use by the Food and Drug Administration (FDA) in the United States or other similar authority in the country where the program is being taught.

• Each DAN AED Training Unit should include: - Manikin with a complete chest to accommodate pad placement

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Between the knowledge development session and skills development session:

1. Instruct the students to thoroughly wash their hands. 2. Clear an area of the classroom where students can be comfortable during the skills development

session. 3. Post "No Smoking" and "Oxygen In Use" signs in the area of the classroom. Any local law or regulation

must be followed. Note: Any local Laws or regulations must be followed Skills Development Session Process:

1. Instruct the students to turn to the appropriate page of Student Handbook as a reference during the skills development session.

2. Introduce the skill and explain its importance and value (when and why the skill might be needed). 3. Demonstrate the skill in "real time" without elaboration or explanation. Students are expected to

reproduce the critical steps of this demonstration. 4. Demonstrate the skill slowly while explaining and elaborating the critical steps to performing the skill. 5. Answer any student questions regarding the performance of the skill. 6. Separate class into groups of three students each (Rescuer, Injured Diver and Observer / Coach). 7. Provide a scenario where the Rescuer will learn and apply the appropriate skills. 8. Recognise reasonable performance of skills and remediate and counsel rescuers to improve

performance as necessary. 9. Debrief the skill and offer suggestions for improvement, identify areas of weakness and reinforce the

rescuer's ability to assist an injured diver. Answer student questions. 10. The Providing Care with an AED skill is an Optional Skill. DAN Instructors should demonstrate this skill

within the Oxygen First Aid course as a means to cross-promote the AED course.

Skills Development Session Overview 1. Scene Safety Assessment Rescuer 1 Rescuer 2 Rescuer 3 2. Initial Assessment With BLS Rescuer 1 Rescuer 2 Rescuer 3 3. AED (Optional) Instructor Demonstration Only Recommended 4. Equipment Identification Rescuer 1 Rescuer 2 Rescuer 3 5. Oxygen Scenario 1 Rescuer 1 - DV w/responsive breathing injured diver 6. Oxygen Scenario 2 Rescuer 2 - DV and NRB w/unresponsive breathing diver 7. Oxygen Scenario 3 Rescuer 3 - ORN, DV and NRB w/unresponsive non-breathing diver

Rescuer 1 - repeat Oxygen Scenario 3 8. Oxygen Scenario 4 Rescuer 2 - ORN, DV w/ unresponsive non-breathing divers who

begins breathing, plus NRB w/ responsive breathing injured diver 9. Disassemble Equipment Rescuer 1 Rescuer 2 Rescuer 3 10. Reassemble Equipment Rescuer 1 Rescuer 2 Rescuer 3 DV = Demand Valve ORN = Oronasal resuscitation mask NRB = Non-rebreather mask BLS = Basic Life Support (Rescue Breathing / CPR

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Skill: Scene Safety Assessment Objective: The student will be able to:

1. Perform a scene safety assessment. 2. List the steps in performing a scene safety assessment. 3. Use appropriate first aid barrier device in a scenario. 4. Demonstrate a caring attitude towards a diver who becomes ill or injured.

Motivation: Protecting yourself is always your first responsibility. You can't help anyone else if you are injured. You should decide if the scene is safe for you to enter and determine if there are any threats that may cause an injury/illness to you, bystanders, or the injured diver while preparing yourself to lend assistance. Required Equipment:

1. Latex or non-latex medical gloves 2. Oronasal resuscitation mask with supplemental oxygen inlet

Recommended Equipment:

1. DAN DSS-Guardian First Aid Kit 2. Plastic resealable bag for barrier device disposal 3. Face shields / safety glasses 4. Other barrier devices as necessary

Instructor Role Students’ Role 1. Introduce skill. 1. Observe Instructor demonstration. 2. Demonstrate skill in "real time." 2. Ask questions. 3. Explain and demonstrate skill. 3. Each student must practice Scene Safety 4. Form groups of three. Assessment. 5. Read skill scenario. 4. Support other students in learning. 6. Oversee student practice. 5. Seek Instructor assistance if difficulties 7. Praise student progress. are experienced. 8. Debrief and remediate as necessary. Scenario: You surfaced about 20 minutes ago after your second dive off of a local charter boat. The boat is currently repositioning to a new site for your third and final dive. Your buddy indicates he has pain in his left shoulder and his left hand is tingling. What should you do first?

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Scene Safety Assessment Follow these simple steps to perform a Scene Safety Assessment. Remember S-A-F-E 1. S - Stop • Stop. • Think. • Act. 2. A - Assess Scene • Is the scene safe? • Is it safe to approach the injured diver? • Is the ventilation adequate for oxygen? • Any other hazards present? 3. F - Find and Secure Oxygen, First Aid Kit and AED unit • First aid kits contain critical supplies such as barriers. 4. E - Exposure Protection: • Use barriers such as gloves and mouth-to-mask barrier devices.

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Skill: Initial Assessment with Basic Life Support Objective: The student will be able to:

1. Check if the injured diver is breathing normally. 2. Provide Adult Basic Life Support (Adult BLS sequence)

Motivation: An injured diver who does not have an open airway or is not breathing normally has little chance for survival unless the ABCs (Airway, Breathing and Circulation) can be restored. The DAN First Aid Provider must be able to open an airway and support ventilation and circulation. Required Equipment:

1. Oronasal resuscitation mask with supplemental oxygen inlet 2. CPR manikins

Recommended Equipment: 1. Latex or non-latex medical gloves 2. Plastic resealable bag for barrier device disposal 3. Other barrier devices as necessary

Instructor Role Students’ Role 1. Introduce skill. 1. Observe Instructor demonstration. 2. Demonstrate skill in "real time." 2. Ask questions. 3. Explain and demonstrate skill. 3. Each student must practice CPR on a 4. Form groups of three. manikin for 2 min. using an oronasal 5. Read skill scenario. resuscitation mask. 6. Oversee student practice. 4. Support other students in learning. 7. Praise student progress. 5. Seek Instructor assistance if difficulties 8. Debrief and remediate as necessary. are experienced. Scenario: You've just finished your first dive of the day. The water was clear, but there was a current. As you turn around to congratulate your buddy on a great dive, you notice a diver near the stern of the boat dropping his gear onto the rack and then slumping to the floor. After conducting a Scene Safety Assessment, what is your next action? What special concern should you have checked in your safety assessment? Victims of drowning: To make adult BLS more suitable for drowning victims, the rescuer should give 5 initial rescue breaths and perform resuscitation for about 1minute before going for help.

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Initial Assessment with Basic Life Support Follow these simple steps to check for normal breathing and to provide Basic Life Support, using the adult BLS sequence.

1. Remember S-A-F-E. 2. Check Responsiveness.

• Gently shake the injured diver’s shoulders and ask loudly: “Are you all right?” • If he responds:

- Leave him in the position in which you find him provided there is no further danger - Try to find out what is wrong with him and get help if needed - Reassess him regularly

• If he does not respond: - Shout for help. - Turn the injured diver on his back and then open the airway using head tilt and chin lift:

o Place your hand on his forehead and gently tilt his head back keeping your thumb and index finger free to close his nose if rescue breathing is required.

o With your fingertips under the point of the injured diver’s chin, lift the chin to open the airway

3. Assess Breathing • Keeping the airway open, look, listen and feel for normal breathing for no more than 10 seconds.

- Look for the chest movement. - Listen at the injured diver’s mouth for breath sounds. - Feel for air on your cheek.

• If he is breathing normally: - Turn him into the recovery position - Send or go for help / call an ambulance - Check for continued breathing

• If he is not breathing normally, send someone for help or, if you are on your own, leave the injured diver and alert the ambulance service; return and start chest compressions as follows: - Kneel by the side of the injured diver - Place one heel of one hand in the centre of the chest - Place the heel of your other hand on top of the first hand - Interlock the fingers of your hands and ensure that pressure is not applied over the injured

diver’s ribs. Do not apply pressure over the upper abdomen or the bottom end of the bony sternum (breastbone).

- Position yourself vertically above the chest and , with your arms straight, press down the sternum 4-5cm

- After each compression, release all the pressure on the chest without loosing contact between your hands and the sternum; repeat a rate of about 100/minute (a little less than 2 compressions every second)

- Compression and release should take equal amounts of time. - After 30 compressions open the airway again using the head tilt and chin lift - Use an oronasal resuscitation mask or pinch the soft part of the nose closed, using the index

finger and thumb of your hand of the forehead . - Allow the mouth to open, but maintain chin lift - Take a normal breath and place your lips on the inlet of the oronasal resuscitation mask, or

around his mouth, making sure that you have a good seal. - Blow steadily in to the mask / mouth while watching the chest to rise, taking about 1 second

as in normal breathing; this is an effective rescue breath. - Maintaining head tilt and chin lift, take your mouth away from the injured diver and watch for

the chest to fall as air passes out. - Take another normal breath and blow into the diver’s mouth (or in the mask), to achieve a

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total of 2 effective rescue breaths. Then return your hands without delay to the correct position on the sternum and give another 30 compressions

- Continue CPR in a ratio of 30:2 - Stop to recheck the injured diver only if he starts breathing normally; otherwise do not

interrupt resuscitation.

• If your initial rescue breath do not make the chest rise as in normal breathing, then before your next attempt: - Check the injured diver’s mouth and remove any obstruction - Recheck that there is adequate head tilt and chin lift - Do not attempt more than 2 breaths each time before returning to chest compressions

Notes: • In the first minutes after cardiac arrest, an injured person may be barely breathing, or taking infrequent,

noisy gasps. Do not confuse this with normal breathing. If you have any doubt whether breathing is normal, act as if not normal.

• If there is more than one rescuer present, another should take over CPR every 1-2 minutes to prevent fatigue. Ensure the minimum delay during the changeover of rescuers

• For victims of drowning: Give 5 initial rescue breaths before starting chest compressions and perform 1 minute of CPR before getting help

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Skill: Providing Care With an AED (Optional) The Providing Care With an AED skill is an Optional Skill. DAN Instructors should demonstrate this skill within the Oxygen Provider course as a means to cross-promote the AED course. Objective: The student will be able to:

1. Recognise the signs of sudden cardiac arrest. 2. Provide defibrillation as soon as possible in the event of cardiac arrest.

Motivation: When an injured diver is in cardiac arrest, CPR can continue to oxygenate the body, but it cannot reset a fibrillating heart. Only a defibrillator can do that. Early access to defibrillators greatly increases an injured diver's chances of survival. With every minute that passes until defibrillation, there is a 7-10 percent decrease in the likelihood of survival from sudden cardiac arrest. Required Equipment:

1. Automated External Defibrillator training unit 2. CPR manikin

Recommended Equipment:

1. Latex or non-latex medical gloves. 2. Oronasal resuscitation mask with supplemental oxygen inlet. 3. Plastic resealable bag for barrier device disposal. 4. Other barrier devices as necessary.

Instructor Role Students’ Role 1. Introduce skill. 1. Observe Instructor demonstration 2. Demonstrate skill in "real time." 2. Ask questions. 3. Explain and demonstrate skill. 4. No student practice recommended. 5. Debrief as necessary. Scenario: You find that the diver in the previous scenario is not breathing normally. You direct your buddy to begin CPR. What do you do next? How long should you conduct CPR before connecting the AED?

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Providing Care with an AED (Optional) 1. Remember S-A-F-E. 2. Unresponsive.

• Shout for help 3. Not breathing normally.

• Send or go for AED • CPR 30:2 until AED is attached • Attach the defibrillator pads to the patient and AED. • Allow the AED to analyse heart rhythm. • Don't touch the patient.

4. If shock required:

• Follow the AED unit's prompts. • Visually and physically clear the patient. • State “I’m clear. You’re clear. All clear.” • Administer shoc. • Resume 30:2 for 2 minutes

5. If no shock required, resume CPR 30:2 until the injured diver starts to breath normally

Note: While AED’s can be used in an aquatic environment, you must dry the chest off before placing the pads. The AED pads should be placed on the injured person's chest according to the diagrams on the pads and then the first aid provider should follow the unit's prompts.

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Skill: Oxygen Equipment Identification Note: Oxygen equipment identification should be taught before any oxygen skill scenarios. Objective: The student will be able to:

1. Identify the component parts of the DAN Oxygen Unit. Motivation: Once the DAN Oxygen Unit is used to assist an injured diver, some of its components must be cleaned for future use. Also, it's important to be able to assemble the equipment to ensure that the equipment is ready for use before every dive outing. Required Equipment:

1. DAN Oxygen Unit or equivalent 2. Oronasal resuscitation mask

Recommended Equipment:

1. Clean sheet for the floor or table to prevent oxygen equipment contamination

Instructor Role Students’ Role 1. Identify the components of the DAN Oxygen Unit. 1. Identify verbally the component parts of 2. Introduce skill. the DAN Oxygen Unit 3. Praise student progress. 2. Student ask questions. 4. Debrief and remediate as necessary. Scenario: It is important to understand the component parts of the DAN Oxygen Unit to be familiar with it in an emergency.

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Oxygen Equipment Identification Identify Standard DAN Oxygen Components A Oronasal resuscitation mask (Pocket Mask) G Barbed constant-flow outlet B T-handle H DISS threaded outlets C Handwheel / wrench I Oronasal mask (Tru-Fit Mask) D Pressure gauge J Demand inhalator valve E Multifunction regulator K Intermediate pressure hose F Constant flow-controller L Oxygen cylinder

M Non-rebreather mask

Note: Depending on the adapter used, there might be confusion about “B”. In this case B is used for the pin index adapter or system. Instructors must tell their students, what kind of connection they use in order to avoid confusion during the exam. If another system than the pin indexing one is used, instructors are allowed to remove “B” on the exam.

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Skill: Demand Inhalator Valve Objective: The student will be able to:

1. Provide oxygen to a responsive breathing injured diver using the demand inhalator valve and oronasal mask.

Motivation: Most diving injuries result in a responsive breathing injured diver exhibiting warning signs of DCI. This skill will show how DAN Oxygen Providers will be able to respond to the most common injured diver scenario and also be able to provide oxygen to themselves in the event they are injured while diving. Required Equipment:

1. DAN Oxygen Unit or equivalent 2. Oronasal mask

Recommended Equipment: 1. Latex or non-latex medical gloves 2. Plastic resealable bag for barrier device disposal 3. Other barrier devices as necessary 4. Various oxygen signs

Instructor Role Students’ Role 1. Introduce skill. 1. Observe Instructor demonstration. 2. Demonstrate skill in "real time." 2. Ask questions. 3. Explain and demonstrate skill. 3. Rescuer 1 must practice providing oxygen to a 4. Form groups of three. simulated injured diver using the demand 5. Read skill scenario. inhalator valve and oronasal mask. 6. Oversee student practice. 4. Support other students in learning. 7. Praise student progress. 5. Seek Instructor assistance if necessary. 8. Debrief and remediate as difficulties are experienced. Scenario: A group of divers from your local dive shop are working on deep diving skills, including several deep dives in preparation for a planned dive trip. After the last divers exit the water, everyone is enjoying a cookout. You notice one of the divers holding his arm and rubbing his shoulder and elbow. What should you do? After a few minutes the injured diver begins to feel better and wants to remove the oxygen mask. How long should the injured diver continue breathing emergency oxygen? What position should you place the injured diver in? Why? Discuss answers. Can the injured diver refuse the rescuer's assistance? Discuss answer.

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Demand Inhalator Valve Follow these simple steps to provide oxygen to a responsive or unresponsive breathing injured diver with the Demand Inhalator Valve. This is the preferred method of providing emergency oxygen to any breathing injured diver. 1. Remember S-A-F-E. 2. Assure the diver is breathing normally. 3. Inform the injured diver that oxygen may help.

• State: "This is oxygen and it may make you feel better. May I help you?" • If the injured diver is unresponsive, permission to help is assumed.

4. Deploy the oxygen unit.

• Open cylinder valve with one complete turn. • Check cylinder pressure. • Assure that there are no leaks in the system. • Constant-flow setting should be in "Off" position. • Take a breath from demand valve and exhale away from it.

5. Place the mask over the injured diver’s mouth and nose.

• Check the mask for any leaks around injured diver's face. 6. Instruct the injured diver to breath normally from the mask.

• Reassure and comfort injured diver. 7. Instruct the injured diver to hold the mask to help maintain a tight seal. 8. Monitor the injured diver and the oxygen pressure gauge.

• Listen for the demand inhalator valve to open during inspiration. • Observe mask fogging during exhalation and clearing with inhalation. • Watch the chest rise during inhalation and fall with exhalation.

9. Activate Emergency Action Plan.

• Call EMS or other appropriate medical facility. • Contact DAN for consultation and coordination of hyperbaric treatment.

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Skill: Non-Rebreather Mask Objective: The student will be able to:

1. Provide oxygen to an unresponsive breathing injured diver using the demand inhalator valve with oronasal mask.

2. Provide oxygen to an unresponsive breathing injured diver using the non-rebreather mask. Motivation: There are some situations where the injured diver may not be able to activate or tolerate the demand inhalator valve and you must be able to provide oxygen by a different method. The second choice of oxygen delivery devices for breathing injured divers is the non-rebreather mask. It can also be used when managing two injured divers. Required Equipment:

1. DAN Oxygen Unit or equivalent 2. Oronasal mask 3. Non-rebreather mask

Recommended Equipment:

1. Latex or non-latex medical gloves 2. Plastic resealable bag for barrier device disposal

Instructor Role             Students’ Role 1. Introduce skill. 1. Observe Instructor demonstration. 2. Demonstrate skill in "real time." 2. Ask questions. 3. Explain and demonstrate skill. 3. Rescuer 2 must practice providing oxygen to a 4. Form groups of three. simulated injured diver using the demand 5. Read skill scenario. inhalator valve with oronasal mask and switch 6. Oversee student practice. to the non-rebreather mask. 7. Praise student progress. 4. Support other students in learning. 8. Debrief and remediate as necessary. 5. Seek Instructor assistance if difficulties are experienced. Scenario: Just after surfacing, a diver in the water suddenly loses consciousness. After getting the diver on board the dive boat, you notice he is still breathing. What should you do? Administer oxygen using the demand valve.

After 30 seconds, you realize the divers isn’t breathing deeply enough and switch to the non-rebreather mask and check the mask for leaks. After a few minutes, the injured diver begins breathing deeply, deflating the reservoir bag of the mask. What should you do? Increase the flow rate on the regulator and continue monitoring the injured diver. What other options do you have if the reservoir bag continues to deflate at a higher flow rate?

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Non-Rebreather Mask Follow these simple steps to provide oxygen to a responsive or unresponsive breathing injured diver with the non-rebreather mask. The non-rebreather mask is ideal when you have two injured divers or an injured diver who will not tolerate the demand inhalator valve. 1. Remember S-A-F-E. 2. Assure the diver is breathing normally. 3. Inform the injured diver that oxygen may help and ask permission to help. 4. Deploy the oxygen unit. 5. Remove non-rebreather mask from bag.

• Stretch oxygen tubing to avoid kinks. • Attach oxygen tubing to barbed constant flow outlet on multifunction regulator.

6. Set constant-flow control to 15 litres per minute (lpm). 7. Prime mask reservoir bag.

• Place a thumb or finger inside the nosepiece, closing the non-return valve, until the reservoir bag fully inflates.

8. Place the mask over the injured diver’s mouth and nose.

• Check the mask for any leaks around injured diver's face. • Adjust the elastic band around head to hold the mask in place. • Squeeze the metal clip over the nose to improve the seal and prevent oxygen leakage.

9. Instruct the injured diver to breathe normally.

• Assure reservoir bag remains inflated. • If not, increase flow rate up to 25 lpm. • Reassure and comfort injured diver.

10. Place the injured diver in the proper position. 11. If responsive, instruct the injured diver to hold mask to maintain a tight seal. 12. Monitor the injured diver and the oxygen pressure system.

• Look for the reservoir bag to slightly inflate and deflate and for movement of the non-return valves. • Observe mask fogging during exhalation and clearing with inhalation. • Watch the chest rise during inhalation and fall with exhalation.

13. Activate Emergency Action Plan.

• Call EMS and DAN.

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Skill: Oronasal Resuscitation Mask Objective: The student will be able to:

1. Establish and maintain BLS for a non-breathing injured diver using an oronasal resuscitation mask with supplemental oxygen.

2. Provide oxygen to an unresponsive breathing injured diver using the demand inhalator valve with oronasal mask

3. Provide oxygen to an unresponsive breathing injured diver using the non-rebreather mask. Motivation: Using an oronasal resuscitation mask with supplemental oxygen when rescue breathing increases the oxygen percentage provided to a non-breathing diver from 16 percent to approximately 50 percent. Establishing and maintaining the airway and breathing is the first priority for the DAN Oxygen Provider when assisting a non-breathing injured diver. Required Equipment:

1. DAN Oxygen Unit or equivalent 2. Oronasal resuscitation mask 3. Oronasal mask 4. Non-rebreather mask

Recommended Equipment:

1. Latex or non-latex medical gloves 2. Plastic resealable bag for barrier device disposal

Instructor Role             Students’ Role 1. Introduce skill. 1. Observe Instructor demonstration. 2. Demonstrate skill in "real time." 2. Ask questions. 3. Explain and demonstrate skill. 3. Rescuer 3 must practice rescue breathing 4. Form groups of three. using oronasal resuscitation mask with 5. Read skill scenario. supplemental O2 for a simulated non-breathing 6. Oversee student practice. injured diver. Additionally, provide O2 to the 7. Praise student progress. injured diver using the demand valve with 8. Debrief and remediate as necessary. oronasal mask and the non-rebreather mask

4. Rescuer 1 repeats scenario. 5. Support other students in learning. 6. Seek Instructor assistance if difficulties are

experienced.

See following page for student scenario.

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Scenario: You are relaxing on the beach when you notice a diver towing her buddy to the shore. You grab your rescue equipment and rush to the water's edge arriving just in time to assist the divers. The injured diver is not breathing and his face has a bluish colour. Students: Begin Adult BLS. Instructor: After three minutes of rescue breaths, you notice that the injured diver's stomach is distended. The injured diver begins vomiting. Clear, re-establish and maintain the airway and ventilations. A minute later the diver begins to cough and resumes breathing. Provide oxygen via the demand inhalator valve with oronasal mask. After a few minutes, the diver vomits again. Students clear the airway. The diver will no longer tolerate the demand valve. Students should switch the diver to the non-rebreather mask. Monitor the injured diver and assure the reservoir bag stays inflated. Instructor: What are the priorities of care when providing oxygen to an injured diver?

1) Scene and oxygen provider safety. 2) Ensuring the ABCs. 3) Provide the highest concentration of oxygen possible. 4) Activate EMS and call DAN.

Important Note: Repeat Scenario with Rescuer #1.

See following page for student handbook reference.

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Oronasal Resuscitation Mask Follow these simple steps to provide oxygen to an unresponsive non-breathing injured diver using the oronasal resuscitation mask. The use of the oronasal resuscitation mask with supplemental oxygen is the preferred method of providing oxygen to a non-breathing injured diver for the single rescuer. IMPORTANT NOTE: Do not delay rescue breathing in order to obtain oxygen. 1. Remember S-A-F-E. 2. Perform Initial assessment, following adult BLS sequence. 3. Activate Emergency Action Plan. 4. Inform the injured diver that oxygen may help and ask permission to help. 5. Deploy the oxygen unit. 6. Prepare the oronasal resuscitation mask.

• Remove mask from case. • Attach one-way valve. • Remove oxygen tubing from the non-rebreather mask. • Attach oxygen tubing to the barbed constant-flow outlet on the multifunction regulator and the oxygen

inlet on the oronasal resuscitation mask. • Set constant-flow control to 15 litres per minute (lpm). • Listen for flow of oxygen.

7. Place the oronasal resuscitation mask over the injured diver’s mouth and nose.

• Adjust the elastic band around head to hold the mask in place. • Maintain open airway and lift the chin up to the mask. • Take a deep breath. • Provide two effective rescue breaths, each taking about 1 second in duration. • Watch for the chest to rise and fall. • Continue CPR 30:2

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Skill: Assisting Two Injured Divers Objective: The student will be able to:

1. Provide oxygen simultaneously to two injured divers. 2. Establish and maintain the Airway and Breathing (perform rescue breathing) for a non-breathing injured

diver using an oronasal resuscitation mask with supplemental oxygen. 3. Provide oxygen to an unresponsive breathing injured diver using the demand inhalator valve with

oronasal mask. 4. Provide oxygen to an unresponsive breathing injured diver using the non-rebreather mask.

Motivation: Since divers are trained to dive in buddy teams, there are situations where the DAN Oxygen Provider will need to provide oxygen to two injured divers simultaneously. Required Equipment:

1. DAN Oxygen Unit or equivalent 2. Oronasal resuscitation mask 3. Non-rebreather mask

Recommended Equipment:

1. Latex or non-latex medical gloves 2. Plastic resealable bag for barrier device disposal

Instructor Role Students’ Role 1. Introduce skill. 1. Ask questions. 2. Form groups of three. 2. Rescuer 2 must practice rescue breathing 3. Read skill scenario. using oronasal resuscitation mask with 4. Oversee student practice. supplemental O2 for a simulated non-breathing 5. Praise student progress. injured diver. Additionally, provide O2 to the 6. Debrief and remediate as necessary. injured diver using the demand inhalator valve

with oronasal mask. On the second injured diver use the non-rebreather mask.

3. Support other students in learning. 4. Seek Instructor assistance if difficulties are experienced

Note: See next page for student scenario.

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Scenario: As a Divemaster, you are leading a group of eight divers on a wreck dive in 90 feet/ 30 meters of water. You turn around to check on the group and you see one of the divers rapidly take off for the surface. The diver's buddy tries to slow him down by holding onto the diver. You signal the group to ascend and you go assist the distressed buddy team. When you and the buddy team get to the surface, the panicked diver is not breathing and the second diver is out of breath. You begin in water ventilations and tow the diver back to the boat. You and the captain get the dive team out of the water Student Action: Begin rescue breathing with supplemental oxygen.

Instructor: After two minutes of rescue breathing, the injured diver begins vomiting.

Clear, re-establish and maintain the airway. The diver begins to spontaneously breathe without assistance. Provide oxygen via demand valve and oronasal mask. Thirty minutes following the dive, as the boat is headed back to shore to meet with EMS, the second diver in the buddy team begins to complain of numbness in the lower extremities. Provide oxygen via the non-rebreather mask. Monitor both injured divers and assure the reservoir bag stays inflated. Instructor: What are the priorities for providing oxygen to two injured divers? Answer: Provide the highest concentration of oxygen to the diver with the worse condition. If both divers have similar signs and symptoms, simply do your best and provide oxygen to both divers.

Note: There are no student pages to accompany this skill.

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Skill: Oxygen Equipment Assembly and Disassembly Note: Oxygen equipment assembly and disassembly may be taught before any oxygen skills scenarios. Objective: The student will be able to:

1. Assemble and disassemble the DAN Oxygen Unit or equivalent. Motivation: Once the DAN Oxygen Unit is used to assist an injured diver, some of its components must be cleaned for future use. Also, it's important to be able to assemble the equipment to ensure that the equipment is ready for use before every dive outing. Required Equipment:

1. DAN Oxygen Unit or equivalent 2. Oronasal resuscitation mask

Recommended Equipment:

1. Clean sheet for the floor or table to prevent oxygen equipment contamination Instructor Role Students’ Role 1. Introduce skill. 1. Rescuer 1 disassemble DAN Oxygen Unit. 2. Form groups of three. 2. Rescuer 2 assemble DAN Oxygen Unit. 3. Read skill scenario. 3. Rescuer 3 disassemble DAN Oxygen Unit. 4. Oversee student practice. 4. Rescuer 1 assemble DAN Oxygen Unit. 5. Praise student progress. 5. Rescuer 2 disassemble DAN Oxygen Unit. 6. Debrief and remediate as necessary. 6. Rescuer 3 assemble DAN Oxygen Unit.

7. Optional: Time rescuers during assembly and disassembly. 8. Optional: Turn off the lights during assembly and disassembly. 9. Support other students in learning. 10. Seek Instructor assistance if difficulties are experienced.

Scenario: After turning over the injured diver to EMS, you must disassemble the DAN Oxygen Unit. Instructor: Talk students through one full assembly / disassembly cycle Student Action: Assemble or disassemble DAN Oxygen Unit. Instructor: Put disassembled oxygen units on clean sheet and mix up the parts. Call out a Rescuer number (1, 2 or 3) and time how long it takes the students to assemble the equipment. Repeat until all students have assembled and disassembled equipment. Optional: Turn out the lights during assembly.

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Skill: Emergency Assistance Plan Objective: The student will be able to:

1. List the components of an Emergency Assistance Plan. 2. Develop an Emergency Assistance Plan for the local diving area.

Motivation: Scuba diving emergencies require that information concerning the diver, the local dive environment and local medical resources is available rapidly in the unlikely event that they are needed. Preparing for an emergency is important to facilitate the best possible outcome for the injured diver. Required Equipment:

1. DAN Oxygen First Aid for Scuba Diving Injuries Student Handbook 2. Rescue slates to write on during an emergency

Recommended Equipment:

1. Communications equipment 2. DAN Oxygen Unit 3. DAN First Aid Kit 4. Automated External Defibrillator

Instructor Role             Students’ Role 1. Introduce skill. 1. Each student compiles his or her own E.A.P 2. Read skill scenario. 2. Ask questions about dive accident management 3. Oversee student progress. 3. Support other students in learning. 4. Praise student success. 4. Seek Instructor assistance if difficulties are 5. Debrief and remediate as necessary. experienced. Scenario: There's a seriously injured diver at your local dive site. What is your Emergency Assistance Plan? What do you do? Whom do you call? Why? Does the type of injury determine whom you call and when you call? What role do you have in the management of scuba diving emergency? Instructor: Talk students through completing an Emergency Assistance Plan for a local dive site. Encourage all course participants to continue their dive education, particularly CPR, first aid and diving accident management skills.

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Emergency Assistance Plan The following information is critical in managing scuba diving injuries. Diver Information: Name: ________________________________________________________ Age: ______________________ Address: _________________________________________________________________________________ Emergency Contact Phone: __________________________________________________________________ Current Complaint: _________________________________________________________________________ _________________________________________________________________________________________ _______________________________________________________________________________________________ Significant Past Medical History (medications, allergies, previous injuries, etc.): ________________________________________________________________________________________ ________________________________________________________________________________________ Dive Profile (Including S.S/Deco) Depth Time Surface Interval Dive # 1 Dive # 2 Dive # 3 Dive # 4 Dive # 5 Exit Water Time: AM/PM Breathing Gas: Air / Nitrox / Mix _________%

Emergency Assistance Plan Initial contact information: ____________________________________________________________________ Emergency Medical Assistance: _______________________________________________________________ Nearest Medical Facility Directions: ____________________________________________________________ ______________________________________________________________________________________________Phone: ___________________________________________________________________________________ Diving Medical consultation Information: _______________________________________________________ Divers Alert Network (DAN) Hotline: __________________________________________________________ Other important information: _________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Phone: ___________________________________________________________________________________

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DAN Oxygen Provider Course Quick Reference Chart.

1. Registration and Introductions 2. Knowledge Development Session [Choose one of these methods.]

• DAN Oxygen First Aid for Scuba Diving Injuries video (50 minutes) • DAN Oxygen First Aid for Scuba Diving Injuries slide series (67 slides) • Combination of both video and slide programs

3. Skills Development Session [Perform the following exercises.]

1. Scene Safety Assessment 2. Basic Life Support 3. Providing Care with an AED (Optional) 4. Equipment Identification 5. Oxygen Scenario 1: Demand valve with responsive breathing injured diver 6. Oxygen Scenario 2: Non-rebreather mask with unresponsive breathing injured diver 7. Oxygen Scenario 3: Rescue breathing using an oronasal resuscitation mask with supplemental oxygen

to assist an unresponsive, non-breathing, injured diver 8. Oxygen Scenario 4: Assisting two injured divers 9. Oxygen Equipment Assembly and Disassembly 10. Emergency Assistance Plan

4. Examination and Review 5. Award DAN Oxygen Provider Wall Certificates or Temporary Cards. 6. Additional time for knowledge and skill remediation for individuals requiring additional practice.